$0 See the chart starting on page 2 for your costs for services this plan covers.

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1 Archdiocese of Chicago BAHMO: Blue Cross and Blue Shield of Illinois Coverage Period: 07/01/ /30/2017 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: ALL Plan Type: HMO This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at or by calling Important Questions Answers Why this Matters: What is the overall deductible? Are there other deductibles for specific services? Is there an out of pocket limit on my expenses? What is not included in the out of pocket limit? Does this plan use a network of providers? Do I need a referral to see a specialist? Are there services this plan doesn t cover? $0 See the chart starting on page 2 for your costs for services this plan covers. No. Yes. $1,500 Individual/$3,000 Family. Prescription copays, premiums, balanced-billed charges, and health care this plan doesn t cover. Yes. Visit or call for a list of Participating providers. Yes. Yes. You don t have to meet deductibles for specific services, but see the chart starting on page 2 for other costs for services this plan covers. The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. Even though you pay these expenses, they don t count toward the out of pocket limit. If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers. This plan will pay some or all of the costs to see a specialist for covered services but only if you have the plan s permission before you see the specialist. Some of the services this plan doesn t cover are listed on page 5. See your policy or plan document for additional information about excluded services. Questions: Call or visit us at If you aren t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. Blue Cross and Blue Shield of Illinois, a] [A] Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association SBC IL Non-HMO LG of 8

2 Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven t met your deductible. The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) This plan may encourage you to use Participating providers by charging you lower deductibles, copayments and coinsurance amounts. Common Medical Event If you visit a health care provider s office or clinic If you have a test Services You May Need Your Cost If You Use a Participating Primary care visit to treat an injury or illness $20 copay/visit Your Cost If You Use a Non-Participating Limitations & Exceptions Services or supplies that are not ordered by your Primary Care Physician or Women s Principal Health Care, except emergency and routine vision exams, are not covered. Specialist visit $30 copay/visit Other practitioner office visit $20 copay/visit Preventive care/screening/immunization No Charge ---none--- Diagnostic test (x-ray, blood work) No Charge Imaging (CT/PET scans, MRIs) No Charge 2 of 8

3 Common Medical Event If you need drugs to treat your illness or condition More information about prescription drug coverage is available at Expressscripts.com If you have outpatient surgery If you need immediate medical attention If you have a hospital stay Services You May Need Generic drugs Your Cost If You Use a Participating $6 for 30 day $14 for a 90 day $32 for a 30 day Your Cost If You Use a Non-Participating Limitations & Exceptions Insulin is charged at generic copay level. There is no additional copayment required for diabetic supplies.contraceptives are covered for medical necessity only for all tiers of Rx coverage. If you fill a prescription for a brandname medication when a generic equivalent is available, you will pay 50% of the difference in cost between the brand and the generic. If you fill a prescription for a brandname medication when a generic equivalent is available, you will pay 50% of the difference in cost between the brand and the generic. Formulary brand drugs $74 for a 90 day $50 for a 30 day Non-Formulary brand drugs $115 for a 90 day covered at the Non- Specialty drugs Formulary brand ---none--- copay level. Facility fee (e.g., ambulatory surgery center) Physician/surgeon fees No Charge Emergency room services visit visit Copay waived if admitted. Emergency medical transportation No Charge No Charge Ground transportation only. Must be affiliated with member s Urgent care $30 copay/visit chosen medical group or referral required. Facility fee (e.g., hospital room) Physician/surgeon fee No Charge 3 of 8

4 Common Medical Event If you have mental health, behavioral health, or substance abuse needs If you are pregnant If you need help recovering or have other special health needs If your child needs dental or eye care Services You May Need Mental/Behavioral health outpatient services Mental/Behavioral health inpatient services Your Cost If You Use a Participating Your Cost If You Use a Non-Participating $20 copay/visit Substance use disorder outpatient services $20 copay/visit Substance use disorder inpatient services Prenatal and postnatal care $15 copay Limitations & Exceptions Unlimited visits. Unlimited days. Use a plan provider only. Unlimited days. Copay applies for the 1 st prenatal visit only. Delivery and all inpatient services ---none--- Home health care No Charge Rehabilitation services No Charge 60 treatments combined for all therapies. Habilitation services No Charge Skilled nursing care Durable medical equipment No Charge Hospice service No Charge Eye exam No Charge Glasses $75 allowance. Dental check-up ---none--- Excludes custodial care. Benefits are limited to items used to serve a medical purpose. DME benefits are provided for both purchase and rental equipment (up to the purchase price). Inpatient copay may apply. Limited to one exam every 24 months at participating providers. 4 of 8

5 Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover (This isn t a complete list. Check your policy or plan document for other excluded services.) Cosmetic Surgery Custodial care Dental care (Adult) Hearing aids Infertility treatment Long-term care Non-emergency care when traveling outside the U.S Private-duty Nursing Routine foot care (with the exception of person with diagnosis of diabetes) Other Covered Services (This isn t a complete list. Check your policy or plan document for other covered services and your costs for these services.) Acupuncture Bariatric surgery Chiropractic care Most coverage provided outside the United States. See Routine eye care (Adult) Weight Loss (except when non-medically supervised) Your Rights to Continue Coverage: If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan. Other limitations on your rights to continue coverage may also apply. For more information on your rights to continue coverage, contact the plan at You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at or or the U.S. Department of Health and Human Services at x61565 or Your Grievance and Appeals Rights: If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact Blue Cross and Blue Shield of Illinois at or visit or contact the U.S Department of Labor's Employee Benefits Security Administration at EBSA (3272) or visit Additionally, a consumer assistance program can help you file your appeal. Contact the Illinois Department of Insurance at (877) or visit 5 of 8

6 Does this Coverage Provide Minimum Essential Coverage? The Affordable Care Act requires most people to have health care coverage that qualifies as minimum essential coverage. This plan or policy does provide minimum essential coverage. Does this Coverage Meet the Minimum Value Standard? The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet the minimum value standard for the benefits it provides. Language Access Services: Spanish (Español): Para obtener asistencia en Español, llame al Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa Chinese (): Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' To see examples of how this plan might cover costs for a sample medical situation, see the next page. 6 of 8

7 About these Coverage Examples: These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. This is not a cost estimator. Don t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different. See the next page for important information about these examples. Having a baby (normal delivery) Amount owed to providers: $7,540 Plan pays $7,250 Patient pays $290 Sample care costs: Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Total $7,540 Patient pays: Deductibles $0 Copays $140 Coinsurance $0 Limits or exclusions $150 Total $290 Managing type 2 diabetes (routine maintenance of a well-controlled condition) Amount owed to providers: $5,400 Plan pays $4,520 Patient pays $830 Sample care costs: Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits and Procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Total $5,400 Patient pays: Deductibles $0 Copays $800 Coinsurance $0 Limits or exclusions $80 Total $880 7 of 8

8 Questions and answers about the Coverage Examples: What are some of the assumptions behind the Coverage Examples? Costs don t include premiums. Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren t specific to a particular geographic area or health plan. The patient s condition was not an excluded or preexisting condition. All services and treatments started and ended in the same coverage period. There are no other medical expenses for any member covered under this plan. Out-of-pocket expenses are based only on treating the condition in the example. The patient received all care from innetwork providers. If the patient had received care from out-of-network providers, costs would have been higher. What does a Coverage Example show? For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn t covered or payment is limited. Does the Coverage Example predict my own care needs? No. Treatments shown are just examples. The care you would receive for this condition could be different based on your doctor s advice, your age, how serious your condition is, and many other factors. Does the Coverage Example predict my future expenses? No. Coverage Examples are not cost estimators. You can t use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows. Can I use Coverage Examples to compare plans? Yes. When you look at the Summary of Benefits and Coverage for other plans, you ll find the same Coverage Examples. When you compare plans, check the Patient Pays box in each example. The smaller that number, the more coverage the plan provides. Are there other costs I should consider when comparing plans? Yes. An important cost is the premium you pay. Generally, the lower your premium, the more you ll pay in out-ofpocket costs, such as copayments, deductibles, and coinsurance. You should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses. Questions: Call or visit us at If you aren t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 8 of 8